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90% of participants will know elements of care specific for four age groups: children, adolescents, adults and the elderly.
After completing this continuing education course, the learner will be able to:
There are significant physical and developmental differences between infants and children, adolescents, adults, and aging adults. This module will discuss those differences and how they influence the healthcare needs of these specific populations.
The anatomy and physiology of an infant or a child differ from an adult's in many ways other than height and weight, and clinical interventions must be applied with these factors in mind. Children have less pulmonary reserve than an adult and have a proportionally higher oxygen requirement. They can maintain central organ perfusion during significant fluid loss because of powerful peripheral vasoconstriction that shunts blood from the limbs to the central circulation. This leads to the cool, mottled extremities and decreased peripheral pulses, which is characteristic of shock in children. Children have less ability to increase cardiac output by increasing cardiac contractility; they maintain cardiac output with tachycardia. Children are more susceptible than adults to heat loss because they have proportionally larger heads and a greater surface-area/body-mass ratio than adults.
The period between 1 month of age and 12 years of age is one of rapid change. Infants and children should be routinely assessed to determine if they are growing normally, and periodic evaluation of physical, emotional, and social development is one of the most important healthcare issues of this patient population. These assessments are performed by comparing the patient to developmental milestones, defined as abilities and behaviors that are normal for a specific age group. When a developmental milestone assessment is done the patient:
Several examples of developmental milestones and assessments are provided here.1 Notice that in infants and very young children, cognitive and language abilities and hand/finger motor abilities are assessed, but visual and perceptual abilities are not.
In terms of movement and physical abilities, an infant 2 to 3 months of age should be able to raise his/her head while lying on the stomach, push up slightly with the arms while on the stomach, open and close the hands, and hold on to and shake objects.
In terms of perceptual ability, an infant 2 to 3 months of age should be able to follow a moving object with her/his eyes and respond to a voice and turn his/her head towards the direction of a sound.
In terms of social and emotional development, an infant 2 to 3 months of age will attempt to mimic facial expressions, begins to smile in response to people, and facial expressions become more numerous and complex.
Warnings signs of a possible serious growth and development issue in this age group include, but are not limited to failure to respond to loud noises or to voice, inability hold onto and move an object, failure to follow a moving object with the eyes, and failing to smile at people.
Children from the ages of 3 to 4 should have the movement and physical abilities to walk unassisted up a flight of stairs one step at a time, pedal a tricycle, throw a ball overhand, and turn a doorknob.
The social and emotional development behaviors that are considered normal for this age group would include the expression of a wide range of emotions, copying adult behavior, and describing what others are feeling.
The cognitive and language abilities of the 3 to 4-year-old child should include an increasingly sophisticated sense of time, the ability to follow a short series of instructions, speaking in sentences and in simple paragraphs, and an ability to name familiar objects and friends.
Warnings signs of a possible severe growth and development issue in this age group include, but are not limited to: Cannot follow simple commands, falls frequently or has difficulty climbing stairs, has unclear speech, does not imitate adults, does not make eye contact, or does not want to play with other children or toys.
The assessment and examination process applied to an infant or a child must be adapted to the behavioral, emotional, and intellectual development of the patient.
Approach an infant or toddler in a calm, gentle and slow manner. Have the caregiver hold the patient when doing an assessment or treatment if possible. If the child has to lie down, let the parent stay next to the child.2 Use warm instruments and warm hands and allow the child to handle equipment if this is safe; some children find this to be reassuring. Explain to the caregiver that the child may cry when a procedure is begun, but that an infant makes no connection between the approaching stimulus and pain. With toddlers, try to make the assessment or treatment of a game to reduce fear. Use your imagination and get the toddler involved by using storybooks, dolls or puppets. Provide reassurance during the assessment or procedure. Praise the child for doing well.
Preschoolers are very active. Motor skills are improving. Mentally, they begin using symbols and improving their memory. They have vivid imaginations, which may cause unseen fears. The preschooler is starting to develop independence, and he/she is sensitive to other’s feelings.
Speak at the language level the child can understand. Explain to the child just before a procedure what is going to be done, using sensory terms when possible. Use games and imagination to gain cooperation. Allow the child to handle the equipment if possible. Enlist the child’s help and allow him to express his feelings. Preschoolers need praise, rewards, and easy to understand rules.
School-aged children grow slowly until puberty. Mentally they are active and eager learners who can understand cause and effect. Building self-esteem is an important task during this period. The school-aged child is developing a greater sense of self, independence, and he wants to fit in with peers. The school-aged child is beginning to make lifestyle choices and may act with poor judgment. Peer pressure, alcohol, sex, drugs, and smoking need to be discussed with this age group.
Because of these issues, the school-aged child needs to be allowed to make decisions when feasible and within reasonable bounds. Provide privacy during assessment or treatment and explain all procedures at the child’s level of understanding. Be prepared to listen and be honest. Tell the child how he/she can be involved in his own care, and have children assist you in their care, if possible. Reassure the child that they did nothing wrong. They need to know that the illness or injury is not a punishment.
The primary safety issues of infancy and childhood are child abuse, accidents, and poisonings.
The incidence of child abuse is difficult to ascertain, but it is a prevalent social issue that has serious short-term and long-term consequences.4,5 The CDC estimated that 1 in 7 children in any year are abused, and this number is likely an underestimate,6 and approximately 12% of abused children are injured (again, likely to be an underestimate) and that 10% of children taken to an ER have been abused or neglected.4,7 In addition, the statistics of child abuse can be deceiving because a child that is abused would be considered one case, but that child is likely to be abused many, many times.
Child abuse can be emotional, physical, psychological, and sexual, and it can also be in the form of neglect and caregiver fabricated illnesses, the last being commonly called Munchhausen by proxy.4, 7, 8 Risk factors for child abuse include (but are not limited to murder)4, 7:
There are many characteristic signs and symptoms and patterns of injury associated with the physical abuse of a child like bruises, burns, specific fractures, and head trauma, all of which are indicators of that child abuse.7 For screening and detection purposes, clinicians should also keep in mind that the emotional and psychological condition of the child and the history surrounding possible incidents of child abuse are important. When considering the possibility of child abuse, consider these three issues.
Healthcare professionals have a duty to report child abuse in professional ethics codes, the standards of healthcare facilities, and state and local statutes. The Federal Child Abuse Prevention and Treatment Act requires every state to have in place procedures that detail who is required to report child abuse, and almost every state designates which professions are included. For more information, see Mandatory Reporters of Child Abuse and Neglect, published by the U.S. Department of Health and Human and available online using this link.
The CDC’s publication Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities, 2016, provides guidelines, plans, and resources for preventing child abuse. The publication can be accessed using this link. Other information from the CDC on this topic is on their website.
Accidental injuries like burns, drowning, falls, and automobile accidents are the number one cause of death in children 4 years of age and younger.4
Poisonings are a significant source of injury to children, as well. Most poisonings happen in children, and every year in the US, hundreds of thousands of children are poisoned or exposed to a potentially toxic substance.9 The CDC reported that every day in the United States 300 children are treated in ERs for a poisoning emergency, and two children die as a result of being poisoned.4
Children are naturally curious, and exploration of the environment is part of the growth process. They are much more likely to use hand-to-mouth behavior to determine the nature of an object, and they also lack the caution of older children. Serious harm and death caused by pediatric exploratory behavior are unusual; however, children are especially vulnerable to the effects of medications and hazardous substances because of body weight, and even one dose of certain medications or a tasting amount of certain substances can cause serious harm or death in a child.10
Poisoning prevention during childhood is often a matter of simple, commonsense interventions like making sure that children cannot have access to medications and hazardous substances. The AAP has a poisoning prevention information/tips page on their website.
Adolescence is a time of significant physical, emotional, and social change.10 Adolescents grow in spurts, mature physically, and are able to reproduce. Mentally, they become more abstract thinkers, can consider many options, are able to choose their own values, and challenge authority. Socially and emotionally, adolescents are developing their own identity and building close relationships. Together all of these processes in the adolescent are termed puberty.
Height and weight gain, the onset of sexual maturity, and cognitive, emotional, and social maturation are the most significant growth and development changes of adolescents. Each adolescent should be examined to ensure that she/he is growing as expected, sexual maturation is developing as expected, and the adolescent’s cognitive, emotional, and social maturation are proceeding normally.
Height and weight should be periodically assessed in all adolescents. Approximately 17-18% of adult height is gained during puberty,9 and the growth spurt typically occurs earlier in girls than in boys. Puberty is also a time in which body weight and lean body mass increase. Bone growth and bone density increase, as well, and adolescence is an important time for bone health. For girls, one half of total body calcium is in place during puberty and up to two-thirds in boys, making this a time of life that can affect the future health of the bones.10 Height and weight should be evaluated with each visit to a primary care physician,4 adolescents should be screened for eating disorders,11 and the USPSTF recommends that “clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.3”
Sexual maturation for the adolescent is assessed by the development of secondary sexual characteristics: breast changes in females, development of pubic hair in females and males, and development of the genitals in males.9 The development of secondary sexual characteristics can be assessed using the sexual maturity rating scale developed by Tanner, e.g., certain changes in breast development by a certain age.9
Cognitive, emotional, and social maturation assessment for the adolescent should be focused on how the adolescent’s development in these areas is affecting adjustment at home, in school, and society.
Safety issues that are of particular concern with adolescents are sexually transmitted diseases, alcohol, drug, and tobacco abuse/use, depression and suicide, accidents and unintentional injuries, especially automobile accidents,4 and interpersonal and sexual violence.12
Major depression in adolescents is a common and serious problem, and it is associated with acute and chronic morbidity, and mortality.14 In 2018 approximately 1 in 7 adolescents aged 12 to 17 had had a major depressive event in the past year, and 1 in 10 had had a major depressive event with severe impairment.13 Major depression in adolescents also frequently goes unrecognized, and the AAP and the USPSTF recommend depression screening starting at age 12.3, 4, 14 The AAP recommends using the Patient Health Questionnaire-2 (PHQ-2) as a screening tool, but clinicians can also use other screening tools; information about these can be found in the GLAD-C toolkit; this can be viewed by using this link.
Over the past two weeks, how often have you been bothered by any of the following problems:
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Suicide is the second leading cause of death in 12 to 25 year-olds, and the suicide rate in American adolescents has been steadily increasing in the past 10 years.15,16,17 Most adolescents who attempt or commit suicide have a serious psychiatric disorder, usually depression. Other factors that put adolescents at risk for suicide include (but are not limited to) anxiety disorders, emotion, physical and sexual trauma, family conflict, feelings of hopelessness, and a stressful life event.17
Accidents and unintentional injuries are the number one cause of death in adolescents, and most of these deaths are caused by automobile accidents.18,19 Risky behavior is common during adolescence. The Youth Risk Behavior Surveillance, 2017, reported that 5.9% of adolescents never or rarely wore a seat belt, 16.5% had ridden in a car driven by someone who had been drinking, 15.7% had carried a weapon, and 13.8% did not use any contraceptive method while having intercourse.20
The Youth Risk Behavior Surveillance, 2017, reported that 6.0% of students had been threatened with a weapon or injured with a weapon, and 23.6% had been in a physical fight.20 As regards sexual violence, 7.4% of students had been forced to have sexual intercourse, and 68.3% had been forced to perform a sexual activity by someone they had been dating.20
The CDC’s program, STOP SV: A Technical Package to Prevent Sexual Violence, is not designed explicitly for adolescents, but it provides basic information on the topic.20 The STOP SV program can be accessed by using this link.
Adults are sexually and physically mature. Their nutritional needs are for maintenance, not growth. Chronic illnesses are either evident at this time of life or have yet to develop, so the adult faces the threat of illness or death from the impact of unhealthy lifestyles. Mentally, they learn new skills and information to solve problems. They are very concerned about affiliation, love, and intimacy: personal identity and an acceptance of self-enable the young adult to form their own independent decisions. Major stress factors occur as this individual establishes a career and family. Their fears include losing their jobs and status in established social relationships. The young adult chooses a lifestyle and career to fulfill goals, seeks closeness with others and may make a commitment to start a family and become an active member of his community.
The middle-aged adult begins to develop physical changes and (possibly) chronic health problems. Women go through menopause. Mentally, they use past experience to learn, create and solve problems. People of this age are concerned about staying productive, and they hope to contribute to future generations and strive to balance dreams with reality. They start planning for retirement and may end up taking care of parents or children.
The later years are a time of significant physical and physiological changes for adults 65 years and older. These physical and physiological changes, the increased prevalence of, and risk for acute and chronic diseases, and the emotional, psychological, social issues particular to aging adults require assessment and screening that are specific to this age group.
Of particular interest are the physiological, physical, and cognitive changes associated with aging. Some of the physiological and physical changes associated with aging are listed in Table 1.21
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Cognitive changes in aging adults are universal and individual. The cognitive decline that is noticeable and problematic is not an inevitable consequence of aging. However, cognitive ability does change with aging,22 some of the changes are listed below, and clinicians would do well to remember these when assessing an older patient.
The assessment of an aging adult should focus on the issues that are specific to this age group. It should also focus on how the physical and physiological changes caused by aging have affected the older adult. A commonly used approach is the Comprehensive Geriatric Assessment (CGA). The CGA is defined as “as a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person23” and it assesses four aspects of the older adult’s health: Functional status, physical health, psychological health, and socio-environmental health.24 The CGA can be structured in different ways, but it typically includes an assessment of the abilities and health status parameters listed in Table 2.
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Assessment and examination are processes of information gathering and information exchange, and with this in mind, they must be adjusted to accommodate the aging adult.
The aging adult may well be accompanied by a family member, and there is evidence indicating that this improves patient satisfaction with the assessment and examination and improves the amount and quality of informant retained by the patient.
There are multiple safety issues that affect the aging adult: two of the most common and serious that are of immediate concern to the healthcare professional are elder abuse and falls.
Elder abuse is a pervasive and serious safety issue for aging adults. According to the National Council on Aging, approximately 1 of every 10 Americans 60 years of age or older have experienced elder abuse, and it has been estimated that only 1 out of 14 cases of elder abuse are reported.25
Elder abuse has been defined in different ways, but it is typically considered to be intentional actions that either cause harm or a risk of harm done by a caregiver or someone in a position of trust.25 There are five types of elder abuse, listed and defined below.26
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Factors that increase the risk for elder abuse include, but are not limited to, advanced age, female gender, dementia, inability to provide self-care, and characteristics of the caretaker.25,26,27 Signs of elder abuse vary depending on the type of abuse. For example, physical abuse can be characterized by bruises, burns, fractures or pressure ulcers; neglect by weight loss, unexplained illnesses, or an unexplained worsening of a chronic health condition.27 Screening patients for elder abuse is recommended by several professional organizations, but there is no evidence that this screening is helpful or effective.28 Screening tools that can be used include the Brief Abuse Screen for the Elderly (BASE) and the Elder Assessment Instrument (EAI).27
A fall is described as an unexpected event in which someone comes to rest on the floor or the ground.29 Falls are a common event in older adults, and it has been estimated that falls occur in 40% of adults 65 years of age and older. The incidence is higher for residents of long-term care facilities and adults over age 75.29 There are multiple risk factors that contribute to falls in the elderly, including (but not limited to) 29:
Falls in the elderly can cause serious injuries and other consequences like impaired mobility, and a fall assessment is recommended for all older adults, at least once a year, and more frequently for at-risk patients.29,30 Screening involves questioning about fall history, e.g., do you have difficulty with balance or gait, have you had a fall in the past 12 months; if the patient or caretaker report positively to the questions, a more formal fall assessment can be done and there are several well-validated screening tests for fall assessment like the Timed Get Up and Go.29,30
Fall prevention strategies can prevent falls, and given the multitude of possible causes, the interventions are done on a case-by-case basis. The patient may need a medication review and adjustment; exercise has been shown to reduce the risk of falls; the patient may need a psychologic intervention, or an environmental intervention is necessary.29,31
